Evaluation and Treatment of Mental Illness in Primary Care

cayenne06, MSN, CNM · Apr 29, 2018

In our primary care site, every patient is screened with a PHQ and if it is positive, the issue is *always* addressed. Depending on what they are originally there for, management might be initiated DOS or they might schedule a follow up to address it specifically. We treat straightforward depression and anxiety, with referrals if the patient does not respond to the treatments we can offer. Acute/severe anxiety is usually referred to psych as our medical director has vetoed any benzo scripts (except pre-procedure) and sometimes that is what they really need, while getting stabilized on a longer term med. After stabilization they may come back to us. Anything beyond depression or anxiety is referred to psych. We don't yet have counseling on site so every patient gets the option to be set up with that as well.

I can't say too much because we haven't rolled out mental health care into my clinic quite yet- we turned one of our clinics from GYN to full primary about a year ago, and are still working on getting all their supports in place. We desperately hope to get funding for a LiCSW or counselor, and also a care coordinator.

I really think having a mental health counselor on staff would be a *huge* benefit. HUGE. So would having a care coordinator (not just for mental health). Having to arrange an appt at another office to get counseling is a bigger barrier than you might think, esp if you are acutely depressed.

Once our primary care center is more settled, we hope to roll out mental health care at my clinic, so maybe I'll have more info soon!

Riburn3, BSN, MSN, APRN, NP · Apr 30, 2018

When I was in Primary care my experience was similar to Cayenne.

Basically would do the PHQ, screen for suicide, either past or present, and perform a detailed depression screen on all new patients, on their annual visit, and if there was anything suspect.

We would treat depression regularly but on a case by case basis, and would refer to psychiatry based on our own clinical judgement. For anxiety we would despense benzo's with a referral to Psych, although for older patients that had taken them for years and you knew they needed them, we would only drug test them to make sure they were actually taking the meds and their grandson wasn't selling them.

Oldmahubbard · May 4, 2018

From my perspective as a Psych NP. While I applaud the willingness of PCP's to prescribe antidepressants and anxiolytics to their patients, I question if they have the background, as well as the time, to do so safely.

One time, I saw a new patient who had gotten an antidepressant from his PCP. He was clearly hypomanic. I discontinued the drug and started him on a mood stabilizer. A month later he was a different person.

Another time, a 16 year old boy was brought in after having seen his PCP a week earlier and gotten a prescription for buspar.

In reality he was having a first psychotic break.

Jules A, MSN · May 4, 2018

For anxiety we would despense benzo's with a referral to Psych, although for older patients that had taken them for years and you knew they needed them, we would only drug test them to make sure they were actually taking the meds and their grandson wasn't selling them.

Yeah we love getting patients from the PCP who started them on the magic pills and then turf off to us. If no indication of Bipolar why not start a SSRI, maybe vistaril prn and if ineffective refer? Not picking on you because this happens all the time but try prying the xanax from their clenched fists once their brain has been tweaked.

My preference is, again if no indication of bipolar which I don't think psych is great at identifying so is even more challenging for primary care, trial SSRI and immediately make a psych referral for therapy at a practice that offers medication management also. That connects the patient to psych services in the event the SSRI isn't helpful and 99.9% would benefit from therapy anyway. Unfortunately folks there really isn't a magic pill that will cure this stuff with the exception of the inappropriate benzos your PCP is so fond of passing out. :)

elkpark · May 4, 2018

I work for the psych consultation-liaison service of a large academic medical center, and nothing drives us crazier than all the individuals we see (esp. all the little old people we see) who are on benzos rx'd by their flipping PCPs. We see soooo many people who are being treated (badly, inappropriately -- you wouldn't believe some of the wacko diagnoses and psychotropic regimens I see) for all kinds of psychiatric disorders by their PCPs. Lots of the little old people are in the acute hospital precisely because they fell and sustained an acute injury because they're oversedated, or delirious, on benzos. Then, in the hospital, we have to deal with whatever their medical problem is plus the benzo detox.

I forget which group it was, but I saw a white paper from one of the US psychiatric (physician) groups a few years ago proposing that the FDA institute rules that only psychiatrists (and, presumably, other psychiatric providers) would be able to prescribe benzos, and only for a few days at a time. I can't tell you how happy it made me to read that, and to picture a world in which that would be the case. Of course, there is no chance in he!! that would ever be implemented (can you imagine the rest of the medical community being willing to give up their right to inappropriately overprescribe benzos to everyone they see??), but it would certainly be a big step in the right direction.

I've been saying for years (decades, now) that if we, the psychiatric community, were out there treating people's diabetes and heart disease and gout and COPD, the rest of the medical community would be after us in an angry mob with torches and pitchforks -- but every yahoo with a license thinks that s/he is competent to treat psychiatric disorders. It's a specialty for a reason, folks. If I had a nickel for every situation I see of people being badly, inappropriately treated for psychiatric issues by their PCP, I wouldn't have to work any more.

What my service would recommend is to refer anything beyond simple depression and anxiety, and, please, for the love of God, don't put people on benzos.

djmatte, ADN, MSN, RN, NP · May 4, 2018

I wish it was that easy to simply "not push people on benzos". As a new provider, I have patients who have been on benzos and opiates for years that I am struggling to reduce. I'm pretty firm with my approach, but that same patient will just simply go to another provider and boom...right back on. Now granted my conscience is clear and I have the luxury of that patient choosing not to see me again, but it's a blanket problem across the board. And between the lack of patient willingness to see mental health or the lack of access to it in the first place, it is kind of laughable that there is ire toward us when we are often the first line if not only providers for a host of mental health problems. But man...if I could just turn every patient I see to the appropriate specialist to handle that whole arena on a dime and spend my life doing physical exams...that would be the life!

Jules A, MSN · May 4, 2018

And between the lack of patient willingness to see mental health or the lack of access to it in the first place, it is kind of laughable that there is ire toward us when we are often the first line if not only providers for a host of mental health problems.

The only ire is toward those initiating benzos and stimulants then turfing them off when it becomes a problem. Start the referral early and there will be less lag time in getting in with psych. Patient lack of willingness to see an appropriate specialist should not be a reason to prescribe meds out of your area of expertise.

djmatte, ADN, MSN, RN, NP · May 4, 2018

The only ire is toward those initiating benzos and stimulants then turfing them off when it becomes a problem. Start the referral early and there will be less lag time in getting in with psych. Patient lack of willingness to see an appropriate specialist should not be a reason to prescribe meds out of your area of expertise.

I'm not justifying others choices. I'm certainly not at the helm for straying down that path. But for things like severe anxiety, it is textbook to prescribe a short run of benzos to bridge until an ssri etc have a chance to take effect. But reality is most of the patients I see in poor and underserved flint Michigan have next to no access to psych. Our facilities are months out and there's no "getting the referral early". Many have been in and out of out for years yet are somehow persistently on 60 Xanax monthly.

FullGlass, BSN, MSN, NP · May 5, 2018

I'm fortunate. I work in an FQHC that has on-site talk therapists and a psychiatrist who does once-weekly onsite visits and telemedicine. The PCPs do manage uncomplicated depression and anxiety, but can instantly consult with the psychiatrist and refer more complicated cases to her. We always encourage patients to have talk therapy in addition to pharmacological treatment. As PCPs, we prescribe benzos with extreme caution and only for short term. SSRIs are preferred. We also do warm hand offs, so if a patient comes to me with a mental health issue, I can walk them over to the behavioral health area and one of those specialists will come out and briefly meet with the patient and help them set up an appointment.

Oldmahubbard · May 5, 2018

I'm fortunate. I work in an FQHC that has on-site talk therapists and a psychiatrist who does once-weekly onsite visits and telemedicine. The PCPs do manage uncomplicated depression and anxiety, but can instantly consult with the psychiatrist and refer more complicated cases to her. We always encourage patients to have talk therapy in addition to pharmacological treatment. As PCPs, we prescribe benzos with extreme caution and only for short term. SSRIs are preferred. We also do warm hand offs, so if a patient comes to me with a mental health issue, I can walk them over to the behavioral health area and one of those specialists will come out and briefly meet with the patient and help them set up an appointment.

Sounds great. Idyllic, even. Everyone under one roof, and all on the same page with the mental health issue.

Unfortunately this is the 1% of mental health treatment.

myelin · May 9, 2018

I agree with the above, straight forward depression and anxiety can (and should) be managed by PCPs. These patients should also be referred to therapy right away. In fact, if the patient has mild/moderate depression they likely should be receiving therapy as a primary treatment anyway. SSRIs do not separate well from placebo for these patients, especially those on the milder end.

If treatment resistant or if you suspect bipolar/something more complicated, please refer to psychiatry. Please do NOT start pt's on benzos and then turf them to psych. At my last FQHC I made a rule that whoever starts the benzo must manage the benzo. The only exception is if they start a short course (and make it clear to the pt that it is a short course) while titrating up an SSRI/referring to me. Also not everyone needs a short course of benzos (most don't). Try Vistaril or gabapentin instead.

When a patient is started on a benzo by their PCP and turfed to psych it can cause a lot of problems, including damaging the relationship between the patient and psychiatrist/psych NP. I inherited a patient with very clear PTSD from his PCP who was a PA. She started him on Xanax. No matter what I did/said he was absolutely convinced that Xanax was the solution to his problems and would not hear anything else. It didn't matter how much data I showed him, how many convos we have about SSRIs/prazosin/exposure therapy/etc. He had been started on that magic pill by his PCP. I maintained boundaries and refused to continue it, but every appointment with him was like pulling teeth. BTW, daily/scheduled benzos are now considered contraindicated and have been shown to damage outcomes for patients with PTSD by the VA.

PCPs starting and maintaining benzos is a huge problem. I always tell patients that daily/scheduled benzos will be continued at a maximum of 4 weeks. I initiate lots of tapers and I have the pt sign a contract. If the pt goes to another provider/is benzo shopping then there are repercussions and they no longer received any scheduled meds from our clinic. Benzo dependence is no joke, and lots of people die because of it. I think one reason why some providers have such cavalier attitudes towards benzo prescribing is they don't see the damage they are doing because it can take years to develop. I did geripsychiatry 2 days/week for 2 years and seeing the effect that chronic benzo use had on my 70+ year-old patients was tragic.

This above rant is mainly focused on daily/scheduled benzo regimens. PRN benzos are another story and I am somewhat looser with those. Although I still expect these patients to be in therapy, attending appts, and on a regimen for managing their anxiety (SSRs, buspirsone, etc). Break through anxiety can happen with some severe cases and I understand that. For those patients I will relent and prescribe a small amount of PRN benzos (5-10 tabs per month max). But if a person is requiring sedation/tranquilization on a daily basis in order to live their life - they are clearly not having their problem managed correctly.

Sorry to write a novel. This is an issue near and dear to my heart after seeing heartbreaking cases of benzo dependence during my geripsychiatry days. Rant over!